Perioperative management - Cholecystectomy, Robotic-Assisted

• Symptomatic cholecystolithiasis or gallbladder sludge with typical biliary colicky pain, often postprandial.
• Asymptomatic cholecystolithiasis with stones >3 cm, gallbladder polyps >1 cm, or porcelain gallbladder (significantly increased gallbladder carcinoma risk).
• Gallstone colic during the first trimester of pregnancy due to the high risk of recurrence later in pregnancy (recommend early elective surgery).
• Acute cholecystitis requiring early laparoscopic surgery within 24 hours of admission.
• Post-ERCP bile duct clearance for concurrent cholecystolithiasis (preferably within 72 hours, “therapeutic splitting”).
• Acute biliary pancreatitis with resolving cholestasis/pancreatitis and no ERCP; early elective surgery is advised due to high recurrence risk of pancreatitis.

Note: Robotic surgery significantly expands the boundaries of minimally invasive procedures, especially for cases that were previously contraindicated.

Contraindications for minimally invasive robot-assisted cholecystectomy include:

• Malignant tumors of the gallbladder or bile ducts requiring extensive resection (though robotic approaches may be feasible)
• Frozen/hostile abdomen
• Acute florid pancreatitis
• Portal vein thrombosis or conditions with severe venous collateralization (e.g., cirrhosis)
• Cirrhosis (Child B and C)
• Severe cardiovascular comorbidities posing an anesthetic risk (e.g., NYHA III with critical carotid stenoses)

Other contraindications to conventional laparoscopic cholecystectomy, such as biliodigestive fistulas or Mirizzi syndrome, may still be approached robotically in expert centers.

• History: Colicky pain (>15 minutes) in the right upper quadrant/epigastrium, jaundice, and fever are main symptoms of inflammatory gallbladder or bile duct disease.
• Clinical Examination: Typical signs of acute cholecystitis include right upper quadrant pain, Murphy’s sign (localized tenderness over the gallbladder on direct pressure), elevated inflammatory markers, and fever.
• Laboratory Workup: Includes complete blood count, CRP, liver enzymes (transaminases), bilirubin, amylase, lipase, coagulation parameters, electrolytes, creatinine, and tumor marker CA 19-9 if malignancy is suspected.
• Abdominal Ultrasound: Detects stones, wall thickening, triple-layered gallbladder wall, and Murphy’s sign in acute cholecystitis.
• Imaging: Avoid additional imaging if no evidence of choledocholithiasis (clinical, lab, or ultrasound) is found.
• ERCP: Therapeutic intent only for choledocholithiasis; use endosonography or MRCP as a diagnostic precursor if necessary.
• Endosonography: Highest sensitivity for detecting common bile duct stones.
• CT/MRCP/MRI: For unclear ultrasound findings or tumor suspicion.
• Gastroscopy: If unclear clinical presentation suggests gastric pathology despite cholecystolithiasis.

General Preparation:

• Previous evening shower
• Shave from jugular notch to symphysis pubis
• Apply Octenisept swab to the navel
• Premedication and single-shot prophylactic antibiotics (e.g., Cefuroxime 1.5 g) in the operating room
  • Perioperative antibiotic therapy is required for acute cholecystitis or choledocholithiasis.
  • Single-shot antibiotic prophylaxis is optional in other cases.
• Thromboprophylaxis with enoxaparin (“Clexane 40”) and anti-thrombosis stockings per VTE prevention guidelines - Prophylaxe der venösen Thromboembolie (VTE)

Anticoagulation Management:

• Continue aspirin therapy perioperatively
• Discontinue clopidogrel (ADP inhibitor) at least 5 days prior
• Pause vitamin K antagonists for 7 - 10 days, monitoring INR
• Pause NOACs (new oral anticoagulants) 2 - 3 days before surgery. Consult cardiologist if needed

Bridging:

• Vitamin K antagonists: Bridge with short-acting heparins if INR is outside the target range
• NOACs: Generally, bridging is unnecessary due to their short half-life, except in high thrombotic risk cases (use UFH in a monitored setting)

Preoperative Functional Diagnostics

• ECG: For patients > 40 years or with pre-existing conditions
• Elevated Cardiac/Pulmonary Risk: Evaluate operability with further diagnostics (chest X-ray, lung function tests, stress ECG, echocardiography, coronary angiography)
• Additional tests depend on comorbidities

• Conversion to open cholecystectomy
• Bile duct injury
• Gallbladder perforation
• Intra-abdominal loss of stones
• Open or minimally invasive bile duct revision
• Intraoperative cholangiography
• Vascular injury (hepatic artery, portal vein)
• Injury of nearby organs (duodenum, small intestine, colon, liver)
• Peritonitis
• Abscess formation
• Follow-up interventions

General anesthesia with intubation is required for procedures involving capnoperitoneum.

• The patient is placed in a supine position on a vacuum cushion, with the left arm optionally abducted. The cushion eliminates the need for additional supports.
• After trocar placement, the operating table is adjusted to approximately a 15° anti-Trendelenburg position with a 5° tilt to the left. The surgical robot is positioned from the right or right cranial side, and the robotic arms are docked.

Notes:

• Proper positioning is crucial for docking the patient to the robotic manipulator. Without a table-motion function, the arms must be undocked before any table adjustments. Patient slippage poses an injury risk.

Important Notes:

• Ensure the vacuum cushion is airtight before sterile draping.

• Primary surgeon: At the console, ideally with visibility of the patient and table assistant
• Table assistant: Positioned on the patient’s left side
• Anesthesiologist: Positioned at the patient’s head on the left side
• Patient cart: Docked from the right/right cranial side
• Instrument nurse: Positioned on the patient’s left side next to the table assistant

Robotic Instruments:

• Prograsp/Tipup grasper
• Fenestrated bipolar forceps
• Camera (30°)
• Monopolar curved scissors
• Large clip applier
• Optional robotic suction-irrigation system

Laparoscopic Instruments:

• Pneumoperitoneum gas system
• Optional laparoscopic suction-irrigation system
• Specimen retrieval bag

Instrument Placement (Right-Handed Configuration):

• Port 1: Fenestrated bipolar forceps
• Port 2: Camera
• Port 3: Monopolar curved scissors or large clip applier
• Port 4: Prograsp/Tipup grasper

Assistant port (if needed): Suction

Trocars:

• Robotic 
  • Four 8-mm robotic trocars
• Laparoscopic
  • Additional assistant trocar, if needed

Base Instruments:

• Scalpel (11 blade)
• scissors
• retractors 
• needle holders 
• suture scissors 
• forceps 
• sponges 
• Veress needle 
• gauzes and suture material (3-0 absorbable for subcutaneous layers, 3-0 monofilament for skin)
• Backhaus clamps
• Plaster

Pain Management:

Nicht-steroidale Antirheumatika sind in der Regel ausreichend, ggf. kann eine Steigerung mit opioidhaltigen Analgetika erfolgen

• Typically managed with non-steroidal anti-inflammatory drugs (NSAIDs). Opioids may be added for breakthrough pain.
• Baseline medication: Oral analgesia with combinations like:
  • Metamizole: 4x 1 g orally or 1 g IV over 10 minutes
  • Paracetamol: 3x 1 g orally, rectally, or IV over 15 minutes
• On-demand medication: For VAS ≥ 4, options include:
  • Piritramide: 7.5 mg IV or subcutaneously
  • Oxigesic: 5 mg acute dose
• Persistent pain may require extended-release opioids (e.g., Targin 10/5 mg twice daily)

Note: Adjust baseline medication to patient factors (age, allergies, renal function). Administer on-demand doses 20 minutes before mobilization if needed.

Note: Refer to the PROSPECT guidelines (Procedures Specific Postoperative Pain Management) and the current guidelines on the management of acute perioperative and post-traumatic pain. - aktuellen Leitlinie Additionally, follow the WHO pain relief ladder for structured pain management.
 
Medical Follow-Up:

• Remove nasogastric tube at the end of surgery
• Check transaminases and bilirubin on postoperative days 1 or 2
• Remove drains on days 2 or 3
• For non-absorbable sutures, remove on days 10 – 12
• If histology reveals carcinoma:
  • pTis or pT1a: Cholecystectomy is sufficient
  • pT1b or higher: Oncologic secondary resection with lymphadenectomy required

Thromboprophylaxis:

• Administer low-molecular-weight heparin (adjust dose by weight/risk factors) alongside physical measures until full mobilization. Monitor renal function and thrombocyte count for HIT II

Activity and Recovery:

• Mobilization: Immediate
• Physiotherapy: Consider respiratory exercises for pneumonia prevention
• Diet: Resume immediately post-op
• Bowel Regulation: Use laxatives from day 2 if needed
• Work Disability: 5–10 days